Focusing on Diabetic Ulcers.

Foot ulcers associated with Diabetes mellitus require immediate attention due to risk of amputation if left untreated. Herein we focus on the mitigating risk factors and physiopathology of the diabetic foot, recounting our own surgical approach and revascularization procedures.

Acute Deep Vein Thrombosis and Pulmonary Embolism: is the Thromboaspiration Device an Appropriate Choice?

Nowadays patients affected by deep vein thrombosis (DVT) and pulmonary embolism (PE) are studied widely but the challenge for physicians is when and how they are to be treated. Most patients present serious comorbidities that can potentially make treatment difficult. An increasing cohort of patients cannot be treated with systemic fibrinolysis but fortunately today, physicians can utilize a number of different instruments to resolve acute DVT and PE.

Abdominal aortic aneurysm.

Endovascular repair of abdominal aortic aneurysm has become a milestone in the treatment of patients with abdominal aortic aneurysm.Technological improvement allows treatment in more and more complex cases. This review summarizes all grafts available in the market. At the best of our knowledge a complete review of most important trial on this topic are provided and at least technical tips and tricks for standard cases are recapitulated.

Family history and ethnicity influencing clinical presentation of type 1 diabetes in childhood.

BACKGROUND: A different clinical presentation of type 1 diabetes (T1DM) could be supposed in children belonging to different ethnicities, with or without family history of autoimmunity. OBJECTIVE: This study investigates the effect of ethnicity and family history of T1DM on clinical characteristics at presentation in a group of T1DM children. METHODS: One hundred ninety-six T1DM children <18 years, consecutively diagnosed during the years 2011-2014, were studied including 91 % of Caucasians of Italian ancestry and 9 % of non-Caucasian origin. RESULTS: Children with 1st or 2nd degree relatives affected by T1DM were younger at disease onset (p = 0.005) and showed lower HbA1C levels (p = 0.002), and higher IAA levels (p = 0.01). Non-Caucasian children were younger at disease onset (p = 0.029), and showed more severe hyperglycemia (p = 0.008) and ketoacidosis (pH p < 0.001). HbA1C levels were negatively related to positive family history of T1DM (p = 0.01), fasting C-peptide levels (p = 0.003), IAA levels (p = 0.03), and IA-2 levels (p = 0.003). The level of pH was positively influenced by fasting C-peptide (p = 0.004), and negatively impacted by C-reactive protein (p = 0.01) and non-Caucasian ethnicity (p = 0.03). CONCLUSION: The milder metabolic decompensation in children with a positive family history of T1DM is probably explained by the awareness of the families in terms of early symptoms of T1DM, while the younger age at onset and the higher levels of autoantibodies may suggest a stronger genetic susceptibility, associated with a more aggressive autoimmune process. The younger age in non-Caucasian children is probably explained by the higher genetic susceptibility in subjects belonging to ethnic groups with a low T1DM incidence. Social aspects and poor living conditions probably predominate in determining the increased severity of metabolic decompensation at onset in children from non-Caucasian ethnicities.

Endovascular first as "preliminary approach" for critical limb ischemia and diabetic foot.

The treatment of the critical limb ischemia (CLI) and diabetic foot (DB) is still object of discussion and the gold standard for revascularization has not yet been identified. In these two decades the introduction of endovascular procedures had a large impact on the surgical revascularization and were added to the practice of vascular surgeons in patients who cannot be candidates for a bypass. This may be due to significant comorbidities, a reduced life expectancy, infection or gangrene in the possible sites of distal anastomoses, the unavailability of suitable veins, or the absence of an adequate "landing zone" for the distal part of the bypass. Various studies have evaluated the role of PTA in DF and CLI that resulted favourable in terms of feasibility, technical efficacy, the reduced number of complications, and limb salvage rates. Anyway, long-term patency is better after bypass surgery than after angioplasty, which is burdened by a high restenosis rate. In our experience we tried to practice endovascular approach as a first choice. If the procedure cannot be concluded safely, we continue the intervention surgically or use a hybrid approach. The endovascular-first strategy seems to be the future regardless of comorbidity of the patient and the degree of pathology. The vascular surgeon remains the only specialist that can decide the correct intervention without pressure or been forced and, last but not least, the only one who can independently perform hybrid interventions.

The role of hybrid procedures in the treatment of critical limb ischemia.

Patients affected by critical limb ischemia (CLI) represent a complex and high risk clinical problem, and a multidisciplinary approach is often demanded. The amputation rate in patients affected by CLI is still high. Introduction of endovascular procedure shook up the CLI concept of treatment. The increasing experience of Vascular Surgeons in endovascular technique forced these specialist to match classic surgical skills and endovascular tools in order to achieve the best treatment for each patients. The combination of the two techniques identifies the hybrid procedure. Aim of this paper is to define indication, necessity and results of the hybrid procedure in patients suffering from CLI.

Computer use, free time activities and metabolic control in patients with type 1 diabetes.

We investigated the influence of computer's use on metabolic control in 115 patients with type 1 diabetes (DM1). Multiple linear regression showed that HbA1c% was not related to age, DM1 duration, TV watching or computer use but was independently and negatively related to the weekly hours spent on physical exercise.

In-stent restenosis after carotid angioplasty and stenting: a challenge for the vascular surgeon.

PURPOSE: This study aims to review the incidence of in-stent restenosis (ISR), the factors which determine restenosis, and to evaluate the use of various endovascular techniques for the management of ISR following carotid artery stenting (CAS). METHODS: Four hundred and seven patients (334 men, mean age 63 years, range 46-86, median 65 years) were treated with CAS between December 2000 and March 2004. Three hundred and seventy-two (89%) patients had at least one ultrasound evaluation performed 6 months after procedure (range 6-40). Recurrent stenosis >80% detected with duplex ultrasound scans were further evaluated by angiography and treated with repeat endovascular procedure. RESULTS: CAS was performed successfully in all cases with a Carotid WallStent (Boston Scientific) using a cerebral protection device (filter). Perioperative complications included four (0.9%) minor and two (0.4%) major strokes these latter two patients died at 5 and 12 days after the operation. No other deaths occurred. A total of 15 carotid arteries (3.6%) in 14 patients had ISR. All ISR were treated with a repeat endovascular procedure: three balloon angioplasty alone, eight angioplasty and secondary stenting, four angioplasty with cutting balloon. Postsurgical restenosis was confirmed to be the only predictive factor for the development of in-stent restenosis (OR 14.5, 95% CI 2.3-113.4, p=0.005). Endovascular treatment of ISR achieved technical success without periprocedurale complications and the absence of significant restenosis over a median follow up time of 12.4 months (range 3.5-30.7). CONCLUSION: Our experience with a large cohort of CAS showed an encouragingly low incidence of ISR (3.6%) and successful treatment by repeat endovascular intervention. We recommend attempting all endovascular possibilities before performing stent removal.